Early symptoms of coeliac disease and IBS can be difficult to identity. Dawn Gay explains how pharmacy teams can spot the warning signs

Wind, constipation, indigestion and diarrhoea are common OTC complaints. The truth is in the figures – the gastrointestinal market is worth a huge £258 million. But gut disorders are not so clear-cut. Complex conditions like coeliac disease, irritable bowel syndrome and inflammatory bowel diseases, from colitis to Crohn’s, present blurred lines for pharmacists who must identify symptoms and impart lifestyle advice.

Coeliac UK released startling new statistics from the University of Nottingham during its recent awareness week (May 12-18). The new research, published in the American Journal of Gastroenterology, shows that coeliac disease, triggered by intolerance to gluten, remains undiagnosed in three-quarters of patients.

Chief executive of Coeliac UK, Sarah Sleet, says: “This latest research shows that nearly a quarter of people with coeliac disease have now been diagnosed and gives an up-to-date picture of the diagnosis levels across the UK. Of course, increasing numbers with a diagnosis is good news and will inevitably mean that there will be an increased demand for gluten-free products in supermarkets. But the three quarters undiagnosed is around 500,000 people – a shocking statistic that needs urgent action.”

Awareness of managing IBS is low, with just 19 per cent of sufferers taking proactive steps to control their condition

The charity has acknowledged that pharmacists have an increasingly important role in helping to identify coeliac symptoms and it launched a learning platform in conjunction with CPPE with tips and answers for pharmacy teams in February. The 'coeliac disease floor', available at www.thelearningpharmacy.com, has 'hotspots' of information aimed at all levels of pharmacy staff.

Pharmacists’ role

Norma McGough, director of evidence and policy at Coeliac UK, says: “Pharmacists are not only integral in helping those already diagnosed to keep to their gluten-free diet and to the provision of their gluten-free food, but they can also provide information to those experiencing the symptoms associated with coeliac disease and signpost to primary care for relevant investigations.”

 The learning platform urges pharmacists to encourage testing. Ms McGough continues: “Pharmacists are well placed to steer people with symptoms of coeliac disease to see their GP for testing. Individuals may go to the pharmacist for advice on medications for anaemia or ongoing gut symptoms or nutritional supplements.”

It is “imperative” that individuals stay on a gluten-containing diet while being tested for coeliac disease, because the markers used to identify the disease – antibodies in the blood and the typical damage to the gut lining – change once gluten has been eliminated from the diet.

This resource also provides clarity on symptoms, which can easily be mistaken for those of other gut disorders like IBS. NICE guidelines on both IBS and coeliac disease recommend that individuals be screened for coeliac disease before a diagnosis of IBS is made. IBS is diagnosed using criteria and/or elimination of other conditions so it has no specific diagnostic test, unlike coeliac disease.

Symptoms of coeliac disease include gut symptoms like recurrent nausea, vomiting, diarrhoea, stomach pain, iron-deficiency anaemia, prolonged fatigue and unexpected weight loss. “It’s also important to look out for people with associated conditions, such as autoimmune thyroid disease and type 1 diabetes or complications such as osteoporosis,” says Ms McGough.

Taboos on constipation

In recent months it has been hard to miss the partly animated TV campaign for Dulcolax constipation remedy, which focuses on overnight relief. Boehringer Ingelheim is also supporting its range – currently the world’s top-selling laxative – with a consumer-focused website, aptly named www.letstalkconstipation.co.uk.

Senior brand manager for consumer healthcare at Boehringer Nikki Milne says: “We continue to support Dulcolax through an extensive TV campaign and view community pharmacy as key to helping consumers in their choice of laxatives, importantly tackling the widely-held myth that you have to be natural to be gentle. Dulcolax provides gentle overnight relief and is the world’s number one laxative range.”

Boehringer added a new pink-packaged liquid product to the range, Dulcolax Pico Liquid, in January. “It’s a sugar-free, great tasting way to get overnight relief from constipation,” says Ms Milne. The Dulcolax Tablets 60 pack has also recently been switched from a P to GSL licence.

IBS relief

It’s been a busy year for another Boehringer brand – Buscopan IBS relief. The tablets, containing the plant derivative hyoscine butylbromide, remain the UK’s number one IBS relief brand. This year the tablets are being marketed via television, digital media and PR, and are supported by an educational consumer website (www.ibs-relief.co.uk), which includes a booklet, diary app and video resources.

A new, larger, loyalty pack of 40 tablets of Buscopan IBS Relief was also launched in March. The range also includes Buscopan Cramps, which relieve non-specific abdominal cramps.

Hazel Richards, Buscopan brand manager, explains the thinking behind the latest campaign: “Our consumer research shows that awareness of managing IBS is low, with just 19 per cent of sufferers taking proactive steps to control their condition. To address this, we have invested heavily in consumer advertising, PR and digital to help drive consumers into pharmacy and to help the pharmacy community with education and other support materials.”

Ms Richards says that pharmacy is often the first port of call for IBS sufferers needing help identifying triggers and bespoke advice: “It’s important that the whole pharmacy team feels confident in giving advice on treatment options and simple lifestyle changes,” she says.

"Patients can easily buy analgesics from grocery stores, so pharmacists can differentiate themselves through quality of service by offering patients bespoke advice. This allows them to help IBS sufferers identify possible triggers and introduce lifestyle changes such as avoiding certain foods.”

Triggers can vary from person to person but often factors such as diet and stress play a part, so it is useful for pharmacy staff to speak to sufferers about what they think the causes are. If they do not know, they should be advised to keep an IBS diary, says Ms Richards. “It is likely that a combination of triggers will cause a flare-up, so a diary is a great way to identify any patterns. This positive support can be vital in helping people take control of their IBS and live a normal life."

Digest the facts

• Inflammatory bowel disease (IBD) affects 260,000 people in the UK. The most common forms that pharmacists are likely to encounter are Crohn’s disease and ulcerative colitis.
• Between 10 and 20 per cent of the western population fulfill the diagnosis criteria for irritable bowel syndrome (IBS). It affects women more often than men and is often triggered by stress.
• One in 100 people in the UK suffer from coeliac disease, but only 24 per cent of sufferers have been diagnosed.
• Approximately 40,700 people were diagnosed with bowel cancer in the UK in 2010, making it the fourth most common cancer.
• More than 10 per cent of a GP’s career is spent dealing with patients suffering from digestive disorders, and around 14 per cent of the national drug budget is spent on gastrointestinal disorders seen in general practice.